System and method for neural-netwok-based atrial fibrillation detection with the aid of a digital computer

ABSTRACT

A system and method for neural-network-based atrial fibrillation detection with the aid of a digital computer are provided. Electrocardiography (ECG) features and annotated patterns of the features are maintained in a database, at least some of the patterns associated with atrial fibrillation. A classifier is trained based on the annotated patterns, the classifier implemented by a convolutional neural network. A representation of an ECG signal recorded by one or more ambulatory monitors is received. ECG features in the representation falling within each of the temporal windows are detected. The trained classifier is used to identify patterns of the ECG features. At least one matrix with weights for the patterns are generated. A value indicative of whether portions of the representation are associated the patient experiencing atrial fibrillation is calculated. That one or more of the portions are associated with the patient experiencing atrial fibrillation is determined.

CROSS-REFERENCE TO RELATED APPLICATION

This present non-provisional patent application is a continuation ofU.S. patent application Ser. No. 16/673,004, filed Nov. 4, 2019,pending; which is a continuation of U.S. Pat. No. 10,463,269, IssuedNov. 5, 2019; which is a continuation-in-part of U.S. Pat. No.10,165,946, Issued Jan. 1, 2019; which is a continuation-in-part of U.S.Pat. No. 9,433,367, issued Sep. 6, 2016; which is a continuation-in-partof U.S. Pat. No. 9,545,204, issued Jan. 17, 2017, and acontinuation-in-part of U.S. Pat. No. 9,730,593, issued Aug. 15, 2017;and which further claims priority under 35 U.S.C. § 119(e) to U.S.Provisional Patent application, Ser. No. 61/882,403, filed Sep. 25,2013, the disclosures of which are incorporated by reference; U.S. Pat.No. 10,463,269, Issued Nov. 5, 2019, also claims priority under 35U.S.C. § 119(e) to U.S. Provisional Patent application, Ser. No.62/591,715, filed Nov. 28, 2017, the disclosure of which is incorporatedby reference.

FIELD

This application relates in general to electrocardiographic monitoringand, in particular, to a system and method for neural-network-basedatrial fibrillation detection with the aid of a digital computer.

BACKGROUND

An electrocardiogram (ECG) records electrical potentials in the heartusing a standardized set format 12-lead configuration to record cardiacelectrical signals from well-established chest locations. Electrodes areplaced on the skin over the anterior thoracic region of the body to thelower right and to the lower left of the sternum, on the left anteriorchest, and on the limbs. The recorded cardiac electrical activity,represented by PQRSTU waveforms, can be interpreted to derive heart rateand physiology, where each P-wave represents atrial electrical activityand the QRSTU components represent ventricular electrical activity.

An ECG is a snapshot of heart function, typically recorded over 12seconds, that can help diagnose rate and regularity of heartbeats,effect of drugs or implantable cardiac devices, and whether a patienthas heart disease. ECGs are limited to recording those heart-relatedaspects present at the time of recording. Thus, an ECG only provides apartial picture and can be insufficient for complete patient diagnosisof many cardiac disorders. Sporadic conditions that may not show upduring a spot ECG recording, including fainting or syncope; rhythmdisorders, such as tachyarrhythmias and bradyarrhythmias; asystolicepisodes; and other cardiac and related disorders, require other meansof diagnosis.

Diagnostic efficacy of cardiac rhythm disorders in particular can beimproved, when appropriate, through long-term extended ECG monitoring.Recording cardiac physiology over an extended period can be challenging,yet is often essential to enabling a physician to identify events ofpotential concern. Although a 30-day observation period is consideredthe “gold standard” of ECG monitoring, achieving 30-day coverage hasproven unworkable because conventional ambulatory ECG monitoring systemsare arduous to employ, cumbersome to wear, and excessively costly.Nevertheless, if a patient's ECG could be recorded in an ambulatorysetting over long periods of time, thereby allowing the patient toengage in activities of daily living, the chances of acquiringmeaningful information and capturing an abnormal cardiac rhythm eventbecomes more likely to be achieved.

For instance, the long-term wear of ECG electrodes is complicated byskin irritation and the inability of conventional ECG electrodes tomaintain continual skin contact after a day or two. Moreover, time,dirt, moisture, and other environmental contaminants, as well asperspiration, skin oil, and dead skin cells from the patient's body, canget between an ECG electrode, the non-conductive adhesive used to adherethe ECG electrode, and the skin's surface. These factors adverselyaffect electrode adhesion and the quality of cardiac signal recordings.Moreover, physical movement and clothing impart compressional, tensile,and torsional forces on electrode contact points decreasing signalquality, especially over long recording times. In addition, aninflexibly fastened ECG electrode is prone to dislodgement that oftenoccurs unbeknownst to the patient, making the ECG recordings worthless.Further, some patients may have skin conditions, such as itching andirritation, aggravated by the wearing of most ECG electrodes. A patientmay have to periodically remove or replace electrodes during a long-termmonitoring period, whether to replace a dislodged electrode, reestablishbetter adhesion, alleviate itching or irritation, allow for cleansing ofthe skin, allow for showering and exercise, or for other purpose. Suchreplacement or slight alteration in electrode location can interferewith the goal of recording the ECG signal for long periods of time.Finally, such recording devices are often ineffective at recordingatrial electrical activity, which is critical in the accurate diagnosisof heart rhythm disorders, because of the use of traditional ECGrecording electronics or due to the location of the monitoringelectrodes far from the origin of the atrial signal, for instance, theP-wave.

Conventionally, Holter monitors are widely used for long-term extendedECG monitoring, typically, for only 24-48 hours. A typical Holtermonitor is a wearable and portable version of an ECG that includescables for each electrode placed on the skin and a separatebattery-powered ECG recorder. Similar to standard in-clinic ECGpractice, the cable and electrode combination (or leads) are placed inthe anterior thoracic region. The duration of a Holter monitoringrecording depends on the sensing and storage capabilities of themonitor, as well as battery life. A “looping” Holter (or event) monitorcan operate for a longer period of time by overwriting older ECGtracings, thence “recycling” storage in favor of extended operation, yetat the risk of losing crucial event data. Holter monitors remaincumbersome, expensive and typically for prescriptive use only, whichlimits their usability. Further, the skill required to properly placethe ECG leads on the patient's chest hinders or precludes a patient fromreplacing or removing the electrodes.

The ZIO XT Patch and ZIO Event Card devices, manufactured by iRhythmTech., Inc., San Francisco, Calif., are wearable stick-on monitoringdevices that are typically worn on the upper left pectoral region torespectively provide continuous and looping ECG recordings. The locationis used to simulate surgically implanted monitors. These devices areprescription-only for single patient use. The ZIO XT Patch device islimited to 14-day monitoring, while the ZIO Event Card device'selectrodes can be worn for up to 30 days. The ZIO XT Patch devicecombines electronic recordation components, including battery, andphysical electrodes into a unitary assembly that adheres to the skin.The ZIO XT Patch device uses adhesive strong enough to support theweight of both the monitor and the electrodes over an extended period oftime. During monitoring, the battery is continually depleted and canpotentially limit overall monitoring duration. The ZIO Event Card deviceis a form of downsized Holter monitor with a recorder component thatmust be removed during activities that could damage the non-waterproofelectronics. These patches have a further limitation because of a smallinter-electrode distance coupled to its designed location ofapplication, high on the left chest. The electrical design of the ZIOpatch and its location make recording high quality atrial signals(P-waves) difficult, as the location is relatively far from the originof these low amplitude signals. As well, the location is suboptimal foridentification of these signals. Furthermore, this patch isproblematical for woman by being placed in a location that may limitsignal quality, especially in woman with large breasts or bosoms. BothZIO devices represent compromises between length of wear and quality ofECG monitoring, especially with respect to ease of long term use,female-friendly fit, and quality of atrial (P-wave) signals.

Personal ambulatory monitoring, both with smartphones or via adjuncts tosmartphones, such as with a wirelessly-connected monitor or activitytracker, of varying degrees of sophistication and interoperability, havebecome increasingly available. For instance, McManus et al., “A NovelApplication for the Detection of an Irregular Pulse using an iPhone 4Sin Patients with Atrial Fibrillation,” Vol. 10(3), pp. 315-319 (March2013), the disclosure of which is incorporated by reference, disclosesobtaining pulsatile time series recordings before and aftercardioversion using the digital camera built into a smartphone. Analgorithm implemented as an app executed by the smartphone analyzedrecorded signals to accurately distinguish pulse recordings duringatrial fibrillation from sinus rhythm, although such a smartphone-basedapproach provides non-continuous observation and would be impracticablefor long term physiological monitoring. Further, thesmartphone-implemented app does not provide continuous recordings,including the provision of pre-event and post-event context, criticalfor an accurate medical diagnosis that might trigger a meaningful andserious medical intervention. In addition, a physician would be loath toundertake a surgical or serious drug intervention without confirmatoryevidence that the wearer in question was indeed the subject of thepresumed rhythm abnormality. Validation of authenticity of the rhythmdisorder for a specified patient takes on critical legal and medicalimportance.

The AliveCor heart monitor, manufactured by AliveCor, Inc., SanFrancisco, Calif., provides a non-continuous, patient-triggered eventmonitor, which is worn on the fingertip. Heart rate is sensed over asingle lead (comparable to Lead I on a conventional ECG) and recorded byan app running on a smartphone, such as an iOS operating system-basedsmartphone, such as the iPhone, manufactured by Apple Inc., Cupertino,Calif., or an Android operating system-based smartphone, manufacturedand offered by various companies, including Google Inc., Mountain View,Calif.; Samsung Electronics Co., Ltd., Suwon, S. Korea; MotorolaMobility LLC, a subsidiary of Google Inc., Libertyville, Ill.; and LGElectronics Inc., Seoul, S. Korea. The Android operating system is alsolicensed by Google Inc. The app can send the data recorded by anAliveCor heart monitor from the smartphone to healthcare providers, whoultimately decide whether to use the data for screening or diagnosticpurposes. Furthermore, as explained supra with respect to the McManusreference, none of these devices provides the context of the arrhythmia,as well as the medico-legal confirmation that would otherwise allow fora genuine medical intervention.

Similarly, adherents to the so-called “Quantified Self” movement combinewearable sensors and wearable computing to self-track activities oftheir daily lives. The Fitbit Tracker, manufactured by Fitbit Inc., SanFrancisco, Calif.; the Jawbone UP, manufactured by Jawbone, SanFrancisco, Calif.; the Polar Loop, manufactured by Polar Electro,Kempele, Finland; and the Nike+ FuelBand, manufactured by Nike Inc.,Beaverton, Oreg., for instance, provide activity trackers worn on thewrist or body with integrated fitness tracking features, such as a heartrate monitor and pedometer to temporally track the number of steps takeneach day with an estimation calories burned. The activity tracker caninterface with a smartphone or computer to allow a wearer to monitortheir progress towards a fitness goal. These activity trackers areaccessories to smartphones, including iOS operating system-basedsmartphones, Android operating system-based smartphones, and WindowsPhone operating-system based smartphones, such as manufactured byMicrosoft Corporation, Redmond, Wash., to which recorded data must beoffloaded for storage and viewing.

The features of activity trackers can also be increasingly found inso-called “smart” watches that combine many of the features of activitytrackers with smartphones. Entire product lines are beginning to beoffered to provide a range of fitness- and health-tracking solutions. Asone example, Samsung Electronics Co., Ltd., offers a line of mobileproducts with fitness-oriented features, including the Galaxy S5smartphone, which incorporates a biometric fingerprint reader and heartrate monitor; the Gear 2 smart watch, which also incorporates a heartrate monitor; and the Gear Fit wearable device, which incorporates aheart rate monitor, real time fitness coaching, and activity tracker.The Galaxy S5 smartphone's heart rate monitor is not meant forcontinuous tracking, while the both the Gear 2 smart watch and Gear Fitwearable device must be paired with a smartphone or computer to offloadand view the recorded data.

With all manner of conventional “fitness-oriented” device, whethersmartphone, smart watch, or activity tracker, quantified physiology istypically tracked for only the personal use of the wearer. Monitoringcan be either continuous or non-continuous. The wearer must take extrasteps to route recorded data to a health care provider; thus, with rareexception, the data is not time-correlated to physician-supervisedmonitoring nor validated. Furthermore, the monitoring is strictlyinformational and medically-significant events, such as serious cardiacrhythm disorders, including tachyarrhythmias and bradyarrhythmias, whilepotentially detectable, are neither identified nor acted upon.

In today's medical and legal environment, a mobile device, such as asmartphone, provides information that cannot be translated into datathat triggers surgery or drug therapy by a physician. In the case of asmartphone detecting a fast heartbeat, for example, such a detection andthe information on the smartphone would neither be identified as trulyrelated to the patient in question or would be deemed sufficient forsubjecting a patient to surgery or potentially toxic drug therapy. Thus,such data that is available today is not actionable in a medicallytherapeutic relevant way. To make such data actionable, one must haverecorded data that allows a specific rhythm diagnosis, and a vaguerecording hinting that something may be wrong with the heart will notsuffice. Further, the recorded data must not only identify theheart-related event of concern, but the signals before and after theevent, which provides critical medical information for a physician todiagnose the disorder specifically. Finally, the recorded data must bemade certifiable, so that the relationship of the recorded data to thepatient that the physician is seeing is clear and appropriatelyidentifiable as an event originating in the patient being examined.Establishing this relationship of data-to-patient has become a legallymandatory step in providing medical care, which heretofore has beenimpracticable insofar as one cannot merely rely upon a smartphone toprovide legally sufficient identification of an abnormality withactionable data such that a patient undergoes a serious medicalintervention.

Even once ECG monitoring data of sufficient length and quality to serveas a basis for a diagnosis is obtained, further challenges exist inproviding an efficient and actionable interpretation of the data. Whilea physician may personally perform an over-read of the data over theentire length of the monitoring manually, such an over-read consumes asignificant amount of time that will slow down delivering any necessarytreatment to the patient. While automated interpretation techniquesexist, such techniques still have significant limitations in recognizingcertain types of cardiac conditions. For example, such techniques mayhave trouble recognizing atrial fibrillation (“AF”), a conditioncharacterized by a rapid, irregular, beating of the atrium. AF isassociated with an increased risk of stroke and heart failure, and isthus an important condition to timely diagnose. Most automatedalgorithms trying to diagnose AF focus on individual features of the ECGwaves, such as particularly focusing on distances between R-waves andcomparing them to predefined thresholds. Such an approach ignores othermanifestations of AF and may lead to misdiagnosis AF is initiallydiagnosed by an absence of organized P-waves 11 and confirmed by erraticventricular rates that manifest in an ECG R-R interval plot as acloud-like pattern of irregular R-R intervals due to an abnormalconduction of impulses to the ventricles.

Therefore, a need remains for an extended wear continuously recordingECG monitor practicably capable of being worn for a long period of timein both men and women and capable of recording high quality atrial andventricular signals reliably.

A further need remains for facilities to integrate wider-rangingphysiological and “life tracking”-type data into long-term ECG andphysiological data monitoring coupled with an onboard ability to cascadeinto the medical records and to the medical authorities appropriatemedical intervention upon detection of a condition of potential medicalconcern.

A still further need remains for a flexible way to detect atrialfibrillation based on results of an ECG monitoring results that allowsto take into account diverse manifestations of atrial fibrillations onan ECG trace.

SUMMARY

Physiological monitoring can be provided through a wearable monitor thatincludes two components, a flexible extended wear electrode patch and aremovable reusable monitor recorder. The wearable monitor sits centrally(in the midline) on the patient's chest along the sternum orientedtop-to-bottom. The placement of the wearable monitor in a location atthe sternal midline (or immediately to either side of the sternum), withits unique narrow “hourglass”-like shape, benefits long-term extendedwear by removing the requirement that ECG electrodes be continuallyplaced in the same spots on the skin throughout the monitoring period.Instead, the patient is free to place an electrode patch anywhere withinthe general region of the sternum, the area most likely to record highquality atrial signals or P-waves. Moreover, the wearable monitor isworn in such a location that is comfortable to woman and allows wearduring activity.

In a further embodiment, the wearable monitor can interoperatewirelessly with other wearable physiology monitors and activity sensorsand with mobile devices, including so-called “smartphones,” as well aswith personal computers and tablet or handheld computers, to downloadmonitoring data either in real-time or in batches. Where a wearablephysiology monitor, activity sensor, or mobile device worn or held bythe patient includes the capability to sense cardiac activity,particularly heart rate, or other physiology, an application executed bythe monitor, sensor, or device can trigger the dispatch of amedically-actionable wearable monitor to the patient upon detectingpotentially medically-significant events, such as cardiac rhythmdisorders, including tachyarrhythmias and bradyarrhythmias. Upon receiptof the wearable monitor, the patient can use the sensor or device, ifappropriately equipped with photographic, fingerprint or thumbprint, orother recording features, to physically record the placement and use ofthe wearable monitor, thereby facilitating the authentication of thedata recorded by the wearable monitor. Finally, the monitor recorder canalso be equipped with a wireless transceiver to either provide data orother information to, or receive data or other information from, aninterfacing wearable physiology monitor, activity sensor, or mobiledevice for relay to an external system or further device, such as aserver, analysis, or for further legal validation of the relationship ofthe monitor to the patient, or for other purpose.

The monitoring patch is especially suited to the female anatomy. Thenarrow longitudinal midsection can fit nicely within the intermammarycleft of the breasts without inducing discomfort, whereas conventionalpatch electrodes are wide and, if adhesed between the breasts,particularly hypertrophic or pendulous breasts, would cause chafing,irritation, frustration, and annoyance, leading to low patientcompliance and possibly premature removal of the monitoring patch.Furthermore, such conventional patches do not have the electrical designand signal processing that would allow recording of the P-wave, giventhe close spacing of the bipolar electrodes.

The foregoing aspects enhance ECG monitoring performance and quality,facilitating long-term ECG recording, critical to accurate arrhythmiadiagnosis.

In addition, the foregoing aspects enhance comfort in women (and certainmen), but not irritation of the breasts, by placing the monitoring patchin the best location possible for optimizing the recording of cardiacsignals from the atrium, another feature critical to proper arrhythmiadiagnosis.

Finally, the foregoing aspects as relevant to monitoring are equallyapplicable to recording other physiological data, such as heart rate,temperature, blood pressure, respiratory rate, blood pressure, bloodsugar (with appropriate subcutaneous probe), oxygen saturation, minuteventilation, as well as other measures of body chemistry and physiology.

Further, instances of atrial fibrillation experienced during a cardiacmonitoring can be flexibly detected using machine learning. ECG trainingdata is obtained and ECG trace features in the data are identified.Patterns of ECG features in the training data are annotated as eitherbeing indicative of a patient having experienced atrial fibrillation ornot indicative of a patient having experienced atrial fibrillation. Anadaptive atrial fibrillation detector is trained on the annotatedpatterns and the trained classifier is used to recognize patterns of ECGfeatures indicative of atrial fibrillation in newly-acquired ECGmonitoring data. Due to being trained on patterns of ECG features, withmore training being possible as more patterns are revealed, the adaptiveatrial fibrillation detector can detect more manifestations of atrialfibrillation recorded during an ECG monitoring that would be availablethrough simple use of predefined parameters, such as distances betweensuccessive R-waves. Once the atrial fibrillation detection is confirmedby an appropriate medical professional, the detection can serve as abasis for initiating an appropriate treatment of the patient or anotheraction.

In one embodiment, a system and method for neural-network-based atrialfibrillation detection with the aid of a digital computer are provided.In a database are maintained a plurality of electrocardiography (ECG)features and annotated patterns of the features, at least some of thepatterns associated with atrial fibrillation. A classifier is trained byan at least on server interconnected to the database based on theannotated patterns in the database, the at least one server implementinga convolutional neural network, the convolutional neural networkincluding two convolutional hidden layers and two fully-connected hiddenlayers, wherein the classifier implemented by the convolutional neuralnetwork. A representation of an ECG signal recorded by one or morecardiac monitors is received by the at least one server. A plurality ofthe ECG features in at least some of the portions of the representationare detected by the at least one server via a first one of theconvolutional hidden layers. The trained classifier is used by the atleast one server via a second one of the convolutional hidden layers toidentify patterns of the ECG features within one or more of the portionsof the ECG signal. At least one matrix with weights for the patterns isgenerated by the at least one server via a first one of thefully-connected hidden layers. For each of the portions, using the atleast one matrix by the at least one server via a second one of thefully-connected hidden layers to calculate a value indicative of whetherthat portion of the representation is associated the patientexperiencing atrial fibrillation. One or more of the portions of the ECGsignal are determined by the at least one server as associated with thepatient experiencing atrial fibrillation using the scores for thoseportions.

Still other embodiments will become readily apparent to those skilled inthe art from the following detailed description, wherein are describedembodiments by way of illustrating the best mode contemplated. As willbe realized, other and different embodiments are possible and theembodiments' several details are capable of modifications in variousobvious respects, all without departing from their spirit and the scope.Accordingly, the drawings and detailed description are to be regarded asillustrative in nature and not as restrictive.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1 and 2 are diagrams showing, by way of examples, an extended wearelectrocardiography and physiological sensor monitor respectively fittedto the sternal region of a female patient and a male patient.

FIG. 3 is a functional block diagram showing a system for remoteinterfacing of an extended wear electrocardiography and physiologicalsensor monitor in accordance with one embodiment.

FIG. 4 is a perspective view showing an extended wear electrode patchwith a monitor recorder inserted.

FIG. 5 is a perspective view showing the monitor recorder of FIG. 4.

FIG. 6 is a perspective view showing the extended wear electrode patchof FIG. 4 without a monitor recorder inserted.

FIG. 7 is a bottom plan view of the monitor recorder of FIG. 4.

FIG. 8 is a top view showing the flexible circuit of the extended wearelectrode patch of FIG. 4 when mounted above the flexible backing.

FIG. 9 is a functional block diagram showing the component architectureof the circuitry of the monitor recorder of FIG. 4.

FIG. 10 is a functional block diagram showing the circuitry of theextended wear electrode patch of FIG. 4.

FIG. 11 is a flow diagram showing a monitor recorder-implemented methodfor monitoring ECG data for use in the monitor recorder of FIG. 4.

FIG. 12 is a graph showing, by way of example, a typical ECG waveform.

FIG. 13 is a flow diagram showing a method for offloading and convertingECG and other physiological data from an extended wearelectrocardiography and physiological sensor monitor in accordance withone embodiment.

FIG. 14 is a flow diagram showing a method machine-learning-based atrialfibrillation detection with the aid of a digital computer in accordancewith one embodiment.

FIG. 15 is a flow diagram showing, by way of example, a routine fortraining an adaptive atrial fibrillation detector for use in the methodof FIG. 14.

FIG. 16 is a flow diagram showing, by way of example, a routine 190 forclassification of ECG data for use in the method 170 of FIG. 14 inaccordance with one embodiment.

DETAILED DESCRIPTION

Physiological monitoring can be provided through a wearable monitor thatincludes two components, a flexible extended wear electrode patch and aremovable reusable monitor recorder. FIGS. 1 and 2 are diagrams showing,by way of examples, an extended wear electrocardiography andphysiological sensor monitor 12, including a monitor recorder 14 inaccordance with one embodiment, respectively fitted to the sternalregion of a female patient 10 and a male patient 11. The wearablemonitor 12 sits centrally (in the midline) on the patient's chest alongthe sternum 13 oriented top-to-bottom with the monitor recorder 14preferably situated towards the patient's head. In a further embodiment,the orientation of the wearable monitor 12 can be correctedpost-monitoring, as further described infra. The electrode patch 15 isshaped to fit comfortably and conformal to the contours of the patient'schest approximately centered on the sternal midline 16 (or immediatelyto either side of the sternum 13). The distal end of the electrode patch15 extends towards the Xiphoid process and, depending upon the patient'sbuild, may straddle the region over the Xiphoid process. The proximalend of the electrode patch 15, located under the monitor recorder 14, isbelow the manubrium and, depending upon patient's build, may straddlethe region over the manubrium.

The placement of the wearable monitor 12 in a location at the sternalmidline 16 (or immediately to either side of the sternum 13)significantly improves the ability of the wearable monitor 12 tocutaneously sense cardiac electric signals, particularly the P-wave (oratrial activity) and, to a lesser extent, the QRS interval signals inthe ECG waveforms that indicate ventricular activity, whilesimultaneously facilitating comfortable long-term wear for many weeks.The sternum 13 overlies the right atrium of the heart and the placementof the wearable monitor 12 in the region of the sternal midline 13 putsthe ECG electrodes of the electrode patch 15 in a location betteradapted to sensing and recording P-wave signals than other placementlocations, say, the upper left pectoral region or lateral thoracicregion or the limb leads. In addition, placing the lower or inferiorpole (ECG electrode) of the electrode patch 15 over (or near) theXiphoid process facilitates sensing of ventricular activity and providessuperior recordation of the QRS interval.

When operated standalone, the monitor recorder 14 of the extended wearelectrocardiography and physiological sensor monitor 12 senses andrecords the patient's ECG data into an onboard memory. In addition, thewearable monitor 12 can interoperate with other devices. FIG. 3 is afunctional block diagram showing a system 120 for remote interfacing ofan extended wear electrocardiography and physiological sensor monitor 12in accordance with one embodiment. The monitor recorder 14 is a reusablecomponent that can be fitted during patient monitoring into anon-conductive receptacle provided on the electrode patch 15, as furtherdescribed infra with reference to FIG. 4, and later removed foroffloading of stored ECG data or to receive revised programming. Themonitor recorder 14 can then be connected to a download station 125,which could be a programmer or other device that permits the retrievalof stored ECG monitoring data, execution of diagnostics on orprogramming of the monitor recorder 14, or performance of otherfunctions. The monitor recorder 14 has a set of electrical contacts (notshown) that enable the monitor recorder 14 to physically interface to aset of terminals 128 on a paired receptacle 127 of the download station125. In turn, the download station 125 executes a communications oroffload program 126 (“Offload”) or similar program that interacts withthe monitor recorder 14 via the physical interface to retrieve thestored ECG monitoring data. The download station 125 could be a server,personal computer, tablet or handheld computer, smart mobile device, orpurpose-built programmer designed specific to the task of interfacingwith a monitor recorder 14. Still other forms of download station 125are possible.

Upon retrieving stored ECG monitoring data from a monitor recorder 14,middleware first operates on the retrieved data to adjust the ECGcapture quality, as necessary, and to convert the retrieved data into aformat suitable for use by third party post-monitoring analysissoftware, as further described infra with reference to FIG. 13. Theformatted data can then be retrieved from the download station 125 overa hard link 135 using a control program 137 (“Ctl”) or analogousapplication executing on a personal computer 136 or other connectablecomputing device, via a communications link (not shown), whether wiredor wireless, or by physical transfer of storage media (not shown). Thepersonal computer 136 or other connectable device may also executemiddleware that converts ECG data and other information into a formatsuitable for use by a third-party post-monitoring analysis program, asfurther described infra with reference to FIG. 13. Note that formatteddata stored on the personal computer 136 would have to be maintained andsafeguarded in the same manner as electronic medical records (EMRs) 134in the secure database 124, as further discussed infra. In a furtherembodiment, the download station 125 is able to directly interface withother devices over a computer communications network 121, which could besome combination of a local area network and a wide area network,including the Internet, over a wired or wireless connection.

A client-server model could be used to employ a server 122 to remotelyinterface with the download station 125 over the network 121 andretrieve the formatted data or other information. The server 122executes a patient management program 123 (“Mgt”) or similar applicationthat stores the retrieved formatted data and other information in asecure database 124 cataloged in that patient's EMRs 134. In addition,the patient management program 123 could manage a subscription servicethat authorizes a monitor recorder 14 to operate for a set period oftime or under pre-defined operational parameters.

The patient management program 123, or other trusted application, alsomaintains and safeguards the secure database 124 to limit access topatient EMRs 134 to only authorized parties for appropriate medical orother uses, such as mandated by state or federal law, such as under theHealth Insurance Portability and Accountability Act (HIPAA) or per theEuropean Union's Data Protection Directive. For example, a physician mayseek to review and evaluate his patient's ECG monitoring data, assecurely stored in the secure database 124. The physician would executean application program 130 (“Pgm”), such as a post-monitoring ECGanalysis program, on a personal computer 129 or other connectablecomputing device, and, through the application 130, coordinate access tohis patient's EMRs 134 with the patient management program 123. Otherschemes and safeguards to protect and maintain the integrity of patientEMRs 134 are possible. The patient management program 123 can alsomanage access to the EMRs by a variety of parties that are authorized toaccess to modify the EMRs.

Prior to storing the results of the monitoring into the EMRs, the EMRs

The wearable monitor 12 can interoperate wirelessly with other wearablephysiology monitors and activity sensors 131, such as activity trackersworn on the wrist or body, and with mobile devices 133, including smartwatches and smartphones. Wearable physiology monitors and activitysensors 131 encompass a wide range of wirelessly interconnectabledevices that measure or monitor a patient's physiological data, such asheart rate, temperature, blood pressure, respiratory rate, bloodpressure, blood sugar (with appropriate subcutaneous probe), oxygensaturation, minute ventilation, and so on; physical states, such asmovement, sleep, footsteps, and the like; and performance, includingcalories burned or estimated blood glucose level. The physiology sensorsin non-wearable mobile devices, particularly smartphones, are generallynot meant for continuous tracking and do not provide medically preciseand actionable data sufficient for a physician to prescribe a surgicalor serious drug intervention; such data can be considered screeninginformation that something may be wrong, but not data that provides thehighly precise information that may allow for a surgery, such asimplantation of a pacemaker for heart block or a defibrillator forventricular tachycardia, or the application of serious medications, likeblood thinners for atrial fibrillation or a cardiac ablation procedure.Such devices, like smartphones, are better suited to pre- andpost-exercise monitoring or as devices that can provide a signal thatsomething is wrong, but not in the sufficient detail and validation toallow for medical action. Conversely, medically actionable wearablesensors and devices sometimes provide continuous recording forrelatively short time periods, but must be paired with a smartphone orcomputer to offload and evaluate the recorded data, especially if thedata is of urgent concern.

Wearable physiology monitors and activity sensors 131, also known as“activity monitors,” and to a lesser extent, “fitness” sensor-equippedmobile devices 133, can trace their life-tracking origins to ambulatorydevices used within the medical community to sense and recordtraditional medical physiology that could be useful to a physician inarriving at a patient diagnosis or clinical trajectory, as well as fromoutside the medical community, from, for instance, sports or lifestyleproduct companies who seek to educate and assist individuals withself-quantifying interests. Data is typically tracked by the wearablephysiology monitors or activity sensors 131 and mobile device 133 foronly the personal use of the wearer. The physiological monitoring isstrictly informational, even where a device originated within themedical community, and the data is generally not time-correlated tophysician-supervised monitoring. Importantly, medically-significantevents, such as cardiac rhythm disorders, including tachyarrhythmias,like ventricular tachycardia or atrial fibrillation, andbradyarrhythmias, like heart block, while potentially detectable withthe appropriate diagnostic heuristics, are neither identified nor actedupon by the wearable physiology monitors and activity sensors 131 andthe mobile device 133.

Frequently, wearable physiology monitors and activity sensors 131 arecapable of wirelessly interfacing with mobile devices 133, particularlysmart mobile devices, including so-called “smartphones” and “smartwatches,” as well as with personal computers and tablet or handheldcomputers, to download monitoring data either in real-time or inbatches. The wireless interfacing of such activity monitors is generallyachieved using transceivers that provide low-power, short-range wirelesscommunications, such as Bluetooth, although some wearable physiologymonitors and activity sensors 131, like their mobile device cohorts,have transceivers that provide true wireless communications services,including 4G or better mobile telecommunications, over atelecommunications network. Other types of wireless and wiredinterfacing are possible.

Where the wearable physiology monitors and activity sensors 131 arepaired with a mobile device 133, the mobile device 133 executes anapplication (“App”) that can retrieve the data collected by the wearablephysiology monitor and activity sensor 131 and evaluate the data togenerate information of interest to the wearer, such as an estimation ofthe effectiveness of the wearer's exercise efforts. Where the wearablephysiology monitors and activity sensors 131 has sufficient onboardcomputational resources, the activity monitor itself executes an appwithout the need to relay data to a mobile device 133. Generally, suchmore computationally-capable wearable physiology monitors and activitysensors are also equipped with wireless communications servicestransceivers, such as found in some smart watches that combine thefeatures of activity monitors with mobile devices. Still other activitymonitor and mobile device functions on the collected data are possible.

In a further embodiment, a wearable physiology monitor, activity sensor131, or mobile device 133 worn or held by the patient 10, or otherwisebe used proximal to the patient's body, can be used to first obtain andthen work collaboratively with a more definitive monitor recorder 14 toenable the collection of physiology by the monitor recorder 14 before,during, and after potentially medically-significant events. The wearablephysiology monitor, activity sensor 131, or mobile device 133 must becapable of sensing cardiac activity, particularly heart rate or rhythm,or other types of physiology or measures, either directly or upon reviewof relayed data. Where the wearable physiology monitor or activitysensor 131 is paired with a mobile device 133, the mobile device 133serves as a relay device and executes an application that will triggerthe dispatch of a monitor recorder 14 to the patient 10 upon detectingpotentially medically-significant events in the data provided by thepaired activity monitor, such as cardiac rhythm disorders, includingtachyarrhythmias and bradyarrhythmias. If the mobile device 133 isitself performing the monitoring of the patient's physiology, the mobiledevice 133 executes an application that will trigger the dispatch of amonitor recorder 14 to the patient 10 in near-real time upon detectingpotentially medically-significant events, thereby avoiding the delayincurred by data relay from an activity monitor. Finally, if thewearable physiology monitor or activity sensor 131 has sufficientonboard computational resources and also is equipped with a wirelesscommunications services transceiver, the wearable physiology monitor oractivity sensor 131 effectively becomes the mobile device 133 andexecutes an application that will trigger the dispatch of a monitorrecorder 14 to the patient 10 in near-real time upon detectingpotentially medically-significant events without the need to firstinterface with a mobile device 133. Still other configurations of thedetection app are possible.

The act of triggering the dispatch of a monitor recorder 14 representsthe first step in a cascade of possible medical interventions ofpotentially increasing seriousness and urgency. Sensors 131 and devices133 are generally not capable of detecting and recording medicallyprecise and actionable data, whereas, as a device designed for extendedwear, the monitor recorder 14 continually monitors the patient'sphysiology over a long time period and will capture anymedically-actionable data leading up to, throughout the occurrence of,and following an event of potential medical concern.

The monitoring data recorded by the monitor recorder 14 can be uploadeddirectly into the patient's EMRs 134, either by using a mobile device133 as a conduit for communications with a server 122 coupled to asecure database 124 within which the patient's EMRs 134 are stored, ordirectly to the server 122, if the monitor recorder 14 is appropriatelyequipped with a wireless transceiver or similar external datacommunications interface, as further described infra. Thus, the datarecorded by the monitor recorder 14 would directly feed into thepatient's EMRs 134, thereby allowing the data to be made certifiable forimmediate use by a physician or healthcare provider. No intermediatesteps would be necessary when going from cutaneously sensing cardiacelectric signals and collecting the patient's physiology using a monitorrecorder 14 to presenting that recorded data to a physician orhealthcare provider for medical diagnosis and care. The direct feedingof data from the monitor recorder 14 to the EMRs 134 clearly establishesthe relationship of the data, as recorded by the monitor recorder 14, tothe patient 10 that the physician is seeing and appropriately identifiesany potentially medically-significant event recorded in the data asoriginating in the patient 10 and nobody else. Based on the monitoringdata, physicians and healthcare providers can rely on the data ascertifiable and can directly proceed with determining the appropriatecourse of treatment for the patient 10, including undertaking furthermedical interventions as appropriate. In a further embodiment, theserver 122 can evaluate the recorded data, as fed into the patient'sEMRs 134, to refer the patient 10 for medical care to a general practicephysician or medical specialist, for instance, a cardiacelectrophysiologist referral from a cardiologist when the recorded dataindicates an event of sufficient potential severity to warrant thepossible implantation of a pacemaker for heart block or a defibrillatorfor ventricular tachycardia. Other uses of the data recorded by themonitor recorder 14 are possible.

For instance, a patient 10 who has previously suffered heart failure isparticularly susceptible to ventricular tachycardia following a periodof exercise or strenuous physical activity. A wearable sensor 131 ordevice 133 that includes a heart rate monitor would be able to timelydetect an irregularity in heart rhythm. The application executed by thesensor 131 or device 133 allows those devices to take action bytriggering the dispatch of a monitor recorder 14 to the patient 10, eventhough the data recorded by the sensor 131 or device 133 is itselfgenerally medically-insufficient for purposes of diagnosis and care.Thus, rather than passively recording patient data, the sensor 131 ordevice 133 takes on an active role in initiating the provisioning ofmedical care to the patient 10 and starts a cascade of appropriatemedical interventions under the tutelage of and followed by physiciansand trained healthcare professionals.

In a still further embodiment, the monitor recorder 14 could upload anevent detection application to the sensor 131 or device 133 to enablethose devices to detect those types of potentially medically-significantevents, which would trigger the dispatch of a monitor recorder 14 to thepatient 10. Alternatively, the event detection application could bedownloaded to the sensor 131 or device 133 from an online applicationstore or similar online application repository. Finally, the monitorrecorder 14 could use the sensor 131 or device 133 to generate anappropriate alert, including contacting the patient's physician orhealthcare services, via wireless (or wired) communications, upondetecting a potentially medically-significant event or in response to apatient prompting.

The patient 10 could be notified by the sensor 131 or device 133,through the sensor's or device's user interface, that an event ofpotential medical concern has been detected coupled with an offer tohave a monitor recorder 14 sent out to the patient 10, assuming that thepatient 10 is not already wearing a monitor recorder 14. Alternatively,the sensor 131 or device 133 could unilaterally send out a request for amonitor recorder 14. The request for a monitor recorder 14 could be sentvia wireless (or wired) communications to the patient's physician, amedical service provider organization, a pharmacy, an emergency medicalservice, or other appropriate healthcare entity that would, in turn,physically provide the patient with a monitor recorder 14. The patient10 could also be told to pick up a monitor recorder 14 directly from oneof the above-identified sources.

Conventional Holter monitors, as well as the ZIO XT Patch and ZIO EventCard devices, described supra, are currently available only by aphysician's prescription for a specific patient 10. As a result, thephysiological data recorded by these monitors and devices are assumed byhealthcare professional to belong to the patient 10. In thisprescriptive medicine context, grave questions as to the authenticity ofthe patient's identity and the data recorded do not generally arise,although current medical practice still favors requesting affirmativepatient and caregiver identification at every step of healthcareprovisioning. As a device intended for adoption and usage broader thanprescriptive medicine, the monitor recorder 14 carries the potential tobe used by more than one individual, which can raise concerns as to theveracity of the data recorded.

In a still further embodiment, the mobile device 133, or, if properlyequipped, the activity monitor, can be used to help authenticate thepatient 10 at the outset of and throughout the monitoring period. Themobile device 133 (or activity monitor) must be appropriately equippedwith a digital camera or other feature capable of recording physicalindicia located within the proximity of the mobile device 133. Forinstance, the Samsung Galaxy S5 smartphone has both a biometricfingerprint reader and autofocusing digital camera built in. Uponreceipt of a monitor recorder 14, the patient 10 can use thephotographic or other recording features of the mobile device 133 (oractivity monitor) to physically record the placement and use of themonitor recorder 14. For instance, the patient 10 could take a pictureor make a video of the monitor recorder 14 using as applied to the chestusing the built-in digital camera. The patient 10 could also swipe afinger over the biometric fingerprint reader. Preferably, the patient 10would include both his or her face or similar uniquely-identifying marksor indicia, such as a scar, tattoo, body piercing, or RFID chip, plusany visible or electronic indicia on the outside of the monitorrecorder's housing, as further described infra with reference to FIG. 5,in the physical recording. The physical recording would then be sent bythe mobile device 133 (or activity monitor) via wireless (or wired)communications to the patient's physician's office or other appropriatecaregiver, thereby facilitating the authentication of the data recordedby the monitor recorder 14. Alternatively, the physical recording couldbe securely stored by the monitor recorder 14 as part of the monitoringdata set.

The mobile device 133 could also serve as a conduit for providing thedata collected by the wearable physiology monitor or activity sensor 131to at least one server 122, or, similarly, the wearable physiologymonitor or activity sensor 131 could itself directly provide thecollected data to the server 122. The server 122 could then merge thecollected data into the wearer's EMRs 134 in the secure database 124, ifappropriate (and permissible), or the server 122 could perform ananalysis of the collected data, perhaps based by comparison to apopulation of like wearers of the wearable physiology monitor oractivity sensor 131. Still other server 122 functions on the collecteddata are possible.

Finally, the monitor recorder 14 can also be equipped with a wirelesstransceiver, as further described infra with reference to FIGS. 9 and10. Thus, when wireless-enabled, both wearable physiology monitors,activity sensors 131, and mobile devices 133 can wirelessly interfacewith the monitor recorder 14, which could either provide data or otherinformation to, or receive data or other information from an interfacingdevice for relay to a further device, such as the server 122, analysis,or other purpose. In addition, the monitor recorder 14 could wirelesslyinterface directly with the server 122, personal computer 129, or othercomputing device connectable over the network 121, when the monitorrecorder 14 is appropriately equipped for interfacing with such devices.Still other types of remote interfacing of the monitor recorder 14 arepossible.

In addition to storing the data received from the monitor 14 recorder aspart of the patient's EMR 134, the server 122 can perform other analysesthat can speed up the processing of the results of the monitoring. Forexample, the server 122 executes an adaptive atrial fibrillationdetector 160, which divides ECG data collected using the monitor 12 intosegments and analyzes each segment to determine whether the patient wasexperiencing atrial fibrillation at the time the segment was recorded.The adaptive atrial fibrillation detector 160 can be implemented by aconvolutional neural network utilizing, for example, a one dimensionalformulation for use with ECG data. Additionally, the adaptive atrialfibrillation detector 160 can include hidden layers for performing theclassification. In the example described below, two convolutional orpooling hidden layers, and two fully-connected hidden layers areutilized. However, other number of layers are possible.

Prior to being used for classification of the segments, the adaptiveatrial fibrillation detector 160 is trained on training data 161, whichcan be stored in the database 124. The training data 161 includes datafiles from ambulatory ECG monitors associated with a group of patients.The patients can be selected randomly or identified based on patientcondition. In one embodiment, between 200 and 250 files can be collectedfrom different ECG ambulatory monitors, such as monitors 12, thoughother kinds of monitors are possible, and used as training data. Theambulatory monitors used to collect the ECG data can include the monitordescribed above with respect to FIGS. 1-10, as well as other types ofmonitors. The data file collected from each ECG ambulatory monitor caneach include up to or more than 64 MB of data, though other sizes arealso possible. As further described below, with reference to FIG. 15,the detector 160 divides the training data 161 into segments of arecorded ECG signal recorded during a particular ECG window. In oneembodiment, the duration of each temporal period can be between 2 and 60seconds, such as 20 seconds, though other durations are also possible.

The database 124 further holds a plurality of ECG features 162, witheach feature being one or more elements of an ECG trace, such asparticular wave (such as P, Q, R, S, or T waves) or a combination ofwaves (such as the QRS complex). Waves or combinations of waves ofdifferent shapes can be stored as different features 161. For example, anarrow QRS complex and a wide QRS complex can be stored as differentfeatures. Similarly, P waves of different height can be stored asdifferent features 162. The features 162 can be extracted from the ECGtraces from the training data 161, though other sources are alsopossible. In one embodiment, a total of 32 features 162 are stored inthe database 124, though other numbers of features 162 are possible.

The server 122 receives annotations 163 of patterns of ECG features 162identified within the training data 161 and provides the annotatedpatterns 163 to the detector 161. Each annotation states whether aparticular pattern of features is associated with atrial fibrillation.For example, a pattern of features can include irregular intervalsbetween two or more successive R waves can be annotated to be associatedwith atrial fibrillation, though other kinds of patterns are alsopossible. Not all irregular patterns are necessarily atrialfibrillation. Many other disorders can mimic atrial fibrillation on thebasis of just irregular rhythms, such as frequent premature atrial orventricular contractions or atrial flutter and atrial tachycardia withvariable AV conduction. Thus, the P-wave sensitive nature of theCarnation Ambulatory Monitor facilitates the machine learningspecificity and sensitivity of true atrial fibrillation detection. Theannotations 163 are made by a user, such as a physician, or usinganother classification tool. The annotated patterns 163 of features 162are run through the detector 160 one or more times, training thedetector 160 to recognize patterns of features associated with atrialfibrillation.

While the annotated patterns 163, the ECG features 162, and the trainingdata 161 are shown with reference to FIG. 3 as being stored in the samedatabase 124 as the EMRs 134, in a further embodiment, the annotatedpatterns 163, the ECG features 162, and the training data 161 could bestored in a different database that is interfaced to the at least oneserver 122 either directly or through the network 121.

The trained classifier is subsequently used to analyze additional ECGdata segments and classify the data as either associated with atrialfibrillation or not, as further described below with reference to FIG.16. Upon classifying an ECG segment as associated with atrialfibrillation, the server 122 can store the classified ECG segments aspart of the EMRs 134 stored in the database 124, as well as take otheractions, such as provide an alert, such as via e-mail or text message,to appropriate medical personnel that could lead to further evaluationof the classified data and the patient receiving an appropriate medicaltreatment. Other kinds of reports that the server 122 can make arepossible. Other kinds of actions that the server 122 can take arepossible.

During use, the electrode patch 15 is first adhesed to the skin alongthe sternal midline 16 (or immediately to either side of the sternum13). A monitor recorder 14 is then snapped into place on the electrodepatch 15 to initiate ECG monitoring. FIG. 4 is a perspective viewshowing an extended wear electrode patch 15 with a monitor recorder 14in accordance with one embodiment inserted. The body of the electrodepatch 15 is preferably constructed using a flexible backing 20 formed asan elongated strip 21 of wrap knit or similar stretchable material witha narrow longitudinal mid-section 23 evenly tapering inward from bothsides. A pair of cut-outs 22 between the distal and proximal ends of theelectrode patch 15 create a narrow longitudinal midsection 23 or“isthmus” and defines an elongated “hourglass”-like shape, when viewedfrom above.

The electrode patch 15 incorporates features that significantly improvewearability, performance, and patient comfort throughout an extendedmonitoring period. During wear, the electrode patch 15 is susceptible topushing, pulling, and torqueing movements, including compressional andtorsional forces when the patient bends forward, and tensile andtorsional forces when the patient leans backwards. To counter thesestress forces, the electrode patch 15 incorporates strain and crimpreliefs, such as described in commonly-assigned U.S. Pat. No. 9,545,204,issued Jan. 17, 2017, the disclosure of which is incorporated byreference. In addition, the cut-outs 22 and longitudinal midsection 23help minimize interference with and discomfort to breast tissue,particularly in women (and gynecomastic men). The cut-outs 22 andlongitudinal midsection 23 further allow better conformity of theelectrode patch 15 to sternal bowing and to the narrow isthmus of flatskin that can occur along the bottom of the intermammary cleft betweenthe breasts, especially in buxom women. The cut-outs 22 and longitudinalmidsection 23 help the electrode patch 15 fit nicely between a pair offemale breasts in the intermammary cleft. Still other shapes, cut-outsand conformities to the electrode patch 15 are possible.

The monitor recorder 14 removably and reusably snaps into anelectrically non-conductive receptacle 25 during use. The monitorrecorder 14 contains electronic circuitry for recording and storing thepatient's electrocardiography as sensed via a pair of ECG electrodesprovided on the electrode patch 15, such as described incommonly-assigned U.S. Pat. No. 9,730,593, issued Aug. 15, 2017, thedisclosure of which is incorporated by reference. The non-conductivereceptacle 25 is provided on the top surface of the flexible backing 20with a retention catch 26 and tension clip 27 molded into thenon-conductive receptacle 25 to conformably receive and securely holdthe monitor recorder 14 in place.

The monitor recorder 14 includes a sealed housing that snaps into placein the non-conductive receptacle 25. FIG. 5 is a perspective viewshowing the monitor recorder 14 of FIG. 4. The sealed housing 50 of themonitor recorder 14 intentionally has a rounded isoscelestrapezoidal-like shape 52, when viewed from above, such as described incommonly-assigned U.S. Design Patent No. D717,955, issued Nov. 18, 2014,the disclosure of which is incorporated by reference. In addition, alabel, barcode, QR code, or other visible or electronic indicia isprinted on the outside of, applied to the outside of, or integrated intothe sealed housing 50 to uniquely identify the monitor recorder 14 andcan include a serial number, manufacturing lot number, date ofmanufacture, and so forth. The edges 51 along the top and bottomsurfaces are rounded for patient comfort. The sealed housing 50 isapproximately 47 mm long, 23 mm wide at the widest point, and 7 mm high,excluding a patient-operable tactile-feedback button 55. The sealedhousing 50 can be molded out of polycarbonate, ABS, or an alloy of thosetwo materials. The button 55 is waterproof and the button's top outersurface is molded silicon rubber or similar soft pliable material. Aretention detent 53 and tension detent 54 are molded along the edges ofthe top surface of the housing 50 to respectively engage the retentioncatch 26 and the tension clip 27 molded into non-conductive receptacle25. Other shapes, features, and conformities of the sealed housing 50are possible.

The electrode patch 15 is intended to be disposable. The monitorrecorder 14, however, is reusable and can be transferred to successiveelectrode patches 15 to ensure continuity of monitoring. The placementof the wearable monitor 12 in a location at the sternal midline 16 (orimmediately to either side of the sternum 13) benefits long-termextended wear by removing the requirement that ECG electrodes becontinually placed in the same spots on the skin throughout themonitoring period. Instead, the patient is free to place an electrodepatch 15 anywhere within the general region of the sternum 13.

As a result, at any point during ECG monitoring, the patient's skin isable to recover from the wearing of an electrode patch 15, whichincreases patient comfort and satisfaction, while the monitor recorder14 ensures ECG monitoring continuity with minimal effort. A monitorrecorder 14 is merely unsnapped from a worn out electrode patch 15, theworn out electrode patch 15 is removed from the skin, a new electrodepatch 15 is adhered to the skin, possibly in a new spot immediatelyadjacent to the earlier location, and the same monitor recorder 14 issnapped into the new electrode patch 15 to reinitiate and continue theECG monitoring.

During use, the electrode patch 15 is first adhered to the skin in thesternal region. FIG. 6 is a perspective view showing the extended wearelectrode patch 15 of FIG. 4 without a monitor recorder 14 inserted. Aflexible circuit 32 is adhered to each end of the flexible backing 20. Adistal circuit trace 33 and a proximal circuit trace (not shown)electrically couple ECG electrodes (not shown) to a pair of electricalpads 34. The electrical pads 34 are provided within a moisture-resistantseal 35 formed on the bottom surface of the non-conductive receptacle25. When the monitor recorder 14 is securely received into thenon-conductive receptacle 25, that is, snapped into place, theelectrical pads 34 interface to electrical contacts (not shown)protruding from the bottom surface of the monitor recorder 14, and themoisture-resistant seal 35 enables the monitor recorder 14 to be worn atall times, even during bathing or other activities that could expose themonitor recorder 14 to moisture.

In addition, a battery compartment 36 is formed on the bottom surface ofthe non-conductive receptacle 25, and a pair of battery leads (notshown) electrically interface the battery to another pair of theelectrical pads 34. The battery contained within the battery compartment35 can be replaceable, rechargeable or disposable.

The monitor recorder 14 draws power externally from the battery providedin the non-conductive receptacle 25, thereby uniquely obviating the needfor the monitor recorder 14 to carry a dedicated power source. FIG. 7 isa bottom plan view of the monitor recorder 14 of FIG. 4. A cavity 58 isformed on the bottom surface of the sealed housing 50 to accommodate theupward projection of the battery compartment 36 from the bottom surfaceof the non-conductive receptacle 25, when the monitor recorder 14 issecured in place on the non-conductive receptacle 25. A set ofelectrical contacts 56 protrude from the bottom surface of the sealedhousing 50 and are arranged in alignment with the electrical pads 34provided on the bottom surface of the non-conductive receptacle 25 toestablish electrical connections between the electrode patch 15 and themonitor recorder 14. In addition, a seal coupling 57 circumferentiallysurrounds the set of electrical contacts 56 and securely mates with themoisture-resistant seal 35 formed on the bottom surface of thenon-conductive receptacle 25.

The placement of the flexible backing 20 on the sternal midline 16 (orimmediately to either side of the sternum 13) also helps to minimize theside-to-side movement of the wearable monitor 12 in the left- andright-handed directions during wear. To counter the dislodgment of theflexible backing 20 due to compressional and torsional forces, a layerof non-irritating adhesive, such as hydrocolloid, is provided at leastpartially on the underside, or contact, surface of the flexible backing20, but only on the distal end 30 and the proximal end 31. As a result,the underside, or contact surface of the longitudinal midsection 23 doesnot have an adhesive layer and remains free to move relative to theskin. Thus, the longitudinal midsection 23 forms a crimp relief thatrespectively facilitates compression and twisting of the flexiblebacking 20 in response to compressional and torsional forces. Otherforms of flexible backing crimp reliefs are possible.

Unlike the flexible backing 20, the flexible circuit 32 is only able tobend and cannot stretch in a planar direction. The flexible circuit 32can be provided either above or below the flexible backing 20. FIG. 8 isa top view showing the flexible circuit 32 of the extended wearelectrode patch 15 of FIG. 4 when mounted above the flexible backing 20.A distal ECG electrode 38 and proximal ECG electrode 39 are respectivelycoupled to the distal and proximal ends of the flexible circuit 32. Astrain relief 40 is defined in the flexible circuit 32 at a locationthat is partially underneath the battery compartment 36 when theflexible circuit 32 is affixed to the flexible backing 20. The strainrelief 40 is laterally extendable to counter dislodgment of the ECGelectrodes 38, 39 due to tensile and torsional forces. A pair of strainrelief cutouts 41 partially extend transversely from each opposite sideof the flexible circuit 32 and continue longitudinally towards eachother to define in S′-shaped pattern, when viewed from above. The strainrelief respectively facilitates longitudinal extension and twisting ofthe flexible circuit 32 in response to tensile and torsional forces.Other forms of circuit board strain relief are possible.

ECG monitoring and other functions performed by the monitor recorder 14are provided through a micro controlled architecture. FIG. 9 is afunctional block diagram showing the component architecture of thecircuitry 60 of the monitor recorder 14 of FIG. 4. The circuitry 60 isexternally powered through a battery provided in the non-conductivereceptacle 25 (shown in FIG. 6). Both power and raw ECG signals, whichoriginate in the pair of ECG electrodes 38, 39 (shown in FIG. 8) on thedistal and proximal ends of the electrode patch 15, are received throughan external connector 65 that mates with a corresponding physicalconnector on the electrode patch 15. The external connector 65 includesthe set of electrical contacts 56 that protrude from the bottom surfaceof the sealed housing 50 and which physically and electrically interfacewith the set of pads 34 provided on the bottom surface of thenon-conductive receptacle 25. The external connector includes electricalcontacts 56 for data download, microcontroller communications, power,analog inputs, and a peripheral expansion port. The arrangement of thepins on the electrical connector 65 of the monitor recorder 14 and thedevice into which the monitor recorder 14 is attached, whether anelectrode patch 15 or download station (not shown), follow the sameelectrical pin assignment convention to facilitate interoperability. Theexternal connector 65 also serves as a physical interface to a downloadstation that permits the retrieval of stored ECG monitoring data,communication with the monitor recorder 14, and performance of otherfunctions.

Operation of the circuitry 60 of the monitor recorder 14 is managed by amicrocontroller 61. The micro-controller 61 includes a program memoryunit containing internal flash memory that is readable and writeable.The internal flash memory can also be programmed externally. Themicro-controller 61 draws power externally from the battery provided onthe electrode patch 15 via a pair of the electrical contacts 56. Themicrocontroller 61 connects to the ECG front end circuit 63 thatmeasures raw cutaneous electrical signals and generates an analog ECGsignal representative of the electrical activity of the patient's heartover time.

The circuitry 60 of the monitor recorder 14 also includes a flash memory62, which the micro-controller 61 uses for storing ECG monitoring dataand other physiology and information. The flash memory 62 also drawspower externally from the battery provided on the electrode patch 15 viaa pair of the electrical contacts 56. Data is stored in a serial flashmemory circuit, which supports read, erase and program operations over acommunications bus. The flash memory 62 enables the microcontroller 61to store digitized ECG data. The communications bus further enables theflash memory 62 to be directly accessed externally over the externalconnector 65 when the monitor recorder 14 is interfaced to a downloadstation.

The circuitry 60 of the monitor recorder 14 further includes anactigraphy sensor 64 implemented as a 3-axis accelerometer. Theaccelerometer may be configured to generate interrupt signals to themicrocontroller 61 by independent initial wake up and free fall events,as well as by device position. In addition, the actigraphy provided bythe accelerometer can be used during post-monitoring analysis to correctthe orientation of the monitor recorder 14 if, for instance, the monitorrecorder 14 has been inadvertently installed upside down, that is, withthe monitor recorder 14 oriented on the electrode patch 15 towards thepatient's feet, as well as for other event occurrence analyses, such asdescribed in commonly-assigned U.S. Pat. No. 9,737,224, issued Aug. 22,2017, the disclosure of which is incorporated by reference.

The circuitry 60 of the monitor recorder 14 includes a wirelesstransceiver 69 that can provides wireless interfacing capabilities. Thewireless transceiver 69 also draws power externally from the batteryprovided on the electrode patch 15 via a pair of the electrical contacts56. The wireless transceiver 69 can be implemented using one or moreforms of wireless communications, including the IEEE 802.11 computercommunications standard, that is Wi-Fi; the 4G mobile phone mobilestandard; the Bluetooth data exchange standard; or other wirelesscommunications or data exchange standards and protocols. The type ofwireless interfacing capability could limit the range ofinteroperability of the monitor recorder 14; for instance,Bluetooth-based implementations are designed for low power consumptionwith a short communications range.

The microcontroller 61 includes an expansion port that also utilizes thecommunications bus. External devices, separately drawing powerexternally from the battery provided on the electrode patch 15 or othersource, can interface to the microcontroller 61 over the expansion portin half duplex mode. For instance, an external physiology sensor can beprovided as part of the circuitry 60 of the monitor recorder 14, or canbe provided on the electrode patch 15 with communication with themicro-controller 61 provided over one of the electrical contacts 56. Thephysiology sensor can include an SpO₂ sensor, blood pressure sensor,temperature sensor, respiratory rate sensor, glucose sensor, airflowsensor, volumetric pressure sensing, or other types of sensor ortelemetric input sources. For instance, the integration of an airflowsensor is described in commonly-assigned U.S. Pat. No. 9,364,155, issuedJun. 14, 2016, the disclosure of which is incorporated by reference.

Finally, the circuitry 60 of the monitor recorder 14 includespatient-interfaceable components, including a tactile feedback button66, which a patient can press to mark events or to perform otherfunctions, and a buzzer 67, such as a speaker, magnetic resonator orpiezoelectric buzzer. The buzzer 67 can be used by the microcontroller61 to output feedback to a patient such as to confirm power up andinitiation of ECG monitoring. Still other components as part of thecircuitry 60 of the monitor recorder 14 are possible.

While the monitor recorder 14 operates under micro control, most of theelectrical components of the electrode patch 15 operate passively. FIG.10 is a functional block diagram showing the circuitry 70 of theextended wear electrode patch 15 of FIG. 4. The circuitry 70 of theelectrode patch 15 is electrically coupled with the circuitry 60 of themonitor recorder 14 through an external connector 74. The externalconnector 74 is terminated through the set of pads 34 provided on thebottom of the non-conductive receptacle 25, which electrically mate tocorresponding electrical contacts 56 protruding from the bottom surfaceof the sealed housing 50 to electrically interface the monitor recorder14 to the electrode patch 15.

The circuitry 70 of the electrode patch 15 performs three primaryfunctions. First, a battery 71 is provided in a battery compartmentformed on the bottom surface of the non-conductive receptacle 25. Thebattery 71 is electrically interfaced to the circuitry 60 of the monitorrecorder 14 as a source of external power. The unique provisioning ofthe battery 71 on the electrode patch 15 provides several advantages.First, the locating of the battery 71 physically on the electrode patch15 lowers the center of gravity of the overall wearable monitor 12 andthereby helps to minimize shear forces and the effects of movements ofthe patient and clothing. Moreover, the housing 50 of the monitorrecorder 14 is sealed against moisture and providing power externallyavoids having to either periodically open the housing 50 for the batteryreplacement, which also creates the potential for moisture intrusion andhuman error, or to recharge the battery, which can potentially take themonitor recorder 14 off line for hours at a time. In addition, theelectrode patch 15 is intended to be disposable, while the monitorrecorder 14 is a reusable component. Each time that the electrode patch15 is replaced, a fresh battery is provided for the use of the monitorrecorder 14, which enhances ECG monitoring performance quality andduration of use. Finally, the architecture of the monitor recorder 14 isopen, in that other physiology sensors or components can be added byvirtue of the expansion port of the microcontroller 61. Requiring thoseadditional sensors or components to draw power from a source external tothe monitor recorder 14 keeps power considerations independent of themonitor recorder 14. Thus, a battery of higher capacity could beintroduced when needed to support the additional sensors or componentswithout effecting the monitor recorders circuitry 60.

Second, the pair of ECG electrodes 38, 39 respectively provided on thedistal and proximal ends of the flexible circuit 32 are electricallycoupled to the set of pads 34 provided on the bottom of thenon-conductive receptacle 25 by way of their respective circuit traces33, 37. The signal ECG electrode 39 includes a protection circuit 72,which is an inline resistor that protects the patient from excessiveleakage current.

Last, in a further embodiment, the circuitry 70 of the electrode patch15 includes a cryptographic circuit 73 to authenticate an electrodepatch 15 for use with a monitor recorder 14. The cryptographic circuit73 includes a device capable of secure authentication and validation.The cryptographic device 73 ensures that only genuine, non-expired,safe, and authenticated electrode patches 15 are permitted to providemonitoring data to a monitor recorder 14, such as described incommonly-assigned U.S. Pat. No. 9,655,538, issued May 23, 2017, thedisclosure of which is incorporated by reference.

In a further embodiment, the circuitry 70 of the electrode patch 15includes a wireless transceiver 75, in lieu the including of thewireless transceiver 69 in the circuitry 60 of the monitor recorder 14,which interfaces with the microcontroller 61 over the microcontroller'sexpansion port via the external connector 74.

The monitor recorder 14 continuously monitors the patient's heart rateand physiology. FIG. 11 is a flow diagram showing a monitorrecorder-implemented method 100 for monitoring ECG data for use in themonitor recorder 14 of FIG. 4. Initially, upon being connected to theset of pads 34 provided with the non-conductive receptacle 25 when themonitor recorder 14 is snapped into place, the microcontroller 61executes a power up sequence (step 101). During the power up sequence,the voltage of the battery 71 is checked, the state of the flash memory62 is confirmed, both in terms of operability check and availablecapacity, and microcontroller operation is diagnostically confirmed. Ina further embodiment, an authentication procedure between themicrocontroller 61 and the electrode patch 15 are also performed.

Following satisfactory completion of the power up sequence, an iterativeprocessing loop (steps 102-109) is continually executed by themicrocontroller 61. During each iteration (step 102) of the processingloop, the ECG frontend 63 (shown in FIG. 9) continually senses thecutaneous ECG electrical signals (step 103) via the ECG electrodes 38,29 and is optimized to maintain the integrity of the P-wave. A sample ofthe ECG signal is read (step 104) by the microcontroller 61 by samplingthe analog ECG signal output front end 63. FIG. 12 is a graph showing,by way of example, a typical ECG waveform 110. The x-axis representstime in approximate units of tenths of a second. The y-axis representscutaneous electrical signal strength in approximate units of millivolts.The P-wave 111 has a smooth, normally upward, that is, positive,waveform that indicates atrial depolarization. The QRS complex usuallybegins with the downward deflection of a Q wave 112, followed by alarger upward deflection of an R-wave 113, and terminated with adownward waveform of the S wave 114, collectively representative ofventricular depolarization. The T wave 115 is normally a modest upwardwaveform, representative of ventricular depolarization, while the U wave116, often not directly observable, indicates the recovery period of thePurkinje conduction fibers.

Sampling of the R-to-R interval enables heart rate informationderivation. For instance, the R-to-R interval represents the ventricularrate and rhythm, while the P-to-P interval represents the atrial rateand rhythm. Importantly, the PR interval is indicative ofatrioventricular (AV) conduction time and abnormalities in the PRinterval can reveal underlying heart disorders, thus representinganother reason why the P-wave quality achievable by the extended wearambulatory electrocardiography and physiological sensor monitordescribed herein is medically unique and important. The long-termobservation of these ECG indicia, as provided through extended wear ofthe wearable monitor 12, provides valuable insights to the patient'scardiac function and overall well-being.

Each sampled ECG signal, in quantized and digitized form, is temporarilystaged in buffer (step 105), pending compression preparatory to storagein the flash memory 62 (step 106). Following compression, the compressedECG digitized sample is again buffered (step 107), then written to theflash memory 62 (step 108) using the communications bus. Processingcontinues (step 109), so long as the monitoring recorder 14 remainsconnected to the electrode patch 15 (and storage space remains availablein the flash memory 62), after which the processing loop is exited andexecution terminates. Still other operations and steps are possible.

In a further embodiment, the monitor recorder 14 also continuouslyreceives data from wearable physiology monitors or activity sensors 131and mobile devices 133 (shown in FIG. 3). The data is received in aconceptually-separate execution thread as part of the iterativeprocessing loop (steps 102-109) continually executed by themicrocontroller 61. During each iteration (step 102) of the processingloop, if wireless data is available (step 140), a sample of the wirelessis read (step 141) by the microcontroller 61 and, if necessary,converted into a digital signal by the onboard ADC of themicrocontroller 61. Each wireless data sample, in quantized anddigitized form, is temporarily staged in buffer (step 142), pendingcompression preparatory to storage in the flash memory 62 (step 143).Following compression, the compressed wireless data sample is againbuffered (step 144), then written to the flash memory 62 (step 145)using the communications bus. Processing continues (step 109), so longas the monitoring recorder 14 remains connected to the electrode patch15 (and storage space remains available in the flash memory 62), afterwhich the processing loop is exited and execution terminates. Stillother operations and steps are possible.

The monitor recorder 14 stores ECG data and other information in theflash memory 62 (shown in FIG. 9) using a proprietary format thatincludes data compression. As a result, data retrieved from a monitorrecorder 14 must first be converted into a format suitable for use bythird party post-monitoring analysis software. FIG. 13 is a flow diagramshowing a method 150 for offloading and converting ECG and otherphysiological data from an extended wear electrocardiography andphysiological sensor monitor 12 in accordance with one embodiment. Themethod 150 can be implemented in software and execution of the softwarecan be performed on a download station 125, which could be a programmeror other device, or a computer system, including a server 122 orpersonal computer 129, such as further described supra with reference toFIG. 3, as a series of process or method modules or steps. Forconvenience, the method 150 will be described in the context of beingperformed by a personal computer 136 or other connectable computingdevice (shown in FIG. 3) as middleware that converts ECG data and otherinformation into a format suitable for use by a third-partypost-monitoring analysis program. Execution of the method 150 by acomputer system would be analogous mutatis mutandis.

Initially, the download station 125 is connected to the monitor recorder14 (step 151), such as by physically interfacing to a set of terminals128 on a paired receptacle 127 or by wireless connection, if available.The data stored on the monitor recorder 14, including ECG andphysiological monitoring data, other recorded data, and otherinformation are retrieved (step 152) over a hard link 135 using acontrol program 137 (“Ctl”) or analogous application executing on apersonal computer 136 or other connectable computing device.

The data retrieved from the monitor recorder 14 is in a proprietarystorage format and each datum of recorded ECG monitoring data, as wellas any other physiological data or other information, must be converted,so that the data can be used by a third-party post-monitoring analysisprogram. Each datum of ECG monitoring data is converted by themiddleware (steps 153-159) in an iterative processing loop. During eachiteration (step 153), the ECG datum is read (step 154) and, ifnecessary, the gain of the ECG signal is adjusted (step 155) tocompensate, for instance, for relocation or replacement of the electrodepatch 15 during the monitoring period.

In addition, depending upon the configuration of the wearable monitor12, other physiological data (or other information), including patientevents, such as a fall, peak activity level, sleep detection, Detectionof patient activity levels and states, and so on, may be recorded alongwith the ECG monitoring data. For instance, actigraphy data may havebeen sampled by the actigraphy sensor 64 based on a sensed eventoccurrence, such as a sudden change in orientation due to the patienttaking a fall. In response, the monitor recorder 14 will embed theactigraphy data samples into the stream of data, including ECGmonitoring data that is recorded to the flash memory 62 by themicro-controller 61. Post-monitoring, the actigraphy data is temporallymatched to the ECG data to provide the proper physiological context tothe sensed event occurrence. As a result, the three-axis actigraphysignal is turned into an actionable event occurrence that is provided,through conversion by the middleware, to third party post-monitoringanalysis programs, along with the ECG recordings contemporaneous to theevent occurrence. Other types of processing of the other physiologicaldata (or other information) are possible.

Thus, during execution of the middleware, any other physiological data(or other information) that has been embedded into the recorded ECGmonitoring data is read (step 156) and time-correlated to the time frameof the ECG signals that occurred at the time that the otherphysiological data (or other information) was noted (step 157). Finally,the ECG datum, signal gain adjusted, if appropriate, and otherphysiological data, if applicable and as time-correlated, are stored ina format suitable to the backend software (step 158) used inpost-monitoring analysis.

In a further embodiment, the other physiological data, if apropos, isembedded within an unused ECG track. For example, the SCP-ENG standardallows multiple ECG channels to be recorded into a single ECG record.The monitor recorder 14, though, only senses one ECG channel. The otherphysiological data can be stored into an additional ECG channel, whichwould otherwise be zero-padded or altogether omitted. The backendsoftware would then be able to read the other physiological data incontext with the single channel of ECG monitoring data recorded by themonitor recorder 14, provided the backend software implemented changesnecessary to interpret the other physiological data. Still other formsof embedding of the other physiological data with formatted ECGmonitoring data, or of providing the other physiological data in aseparate manner, are possible.

Processing continues (step 159) for each remaining ECG datum, afterwhich the processing loop is exited and execution terminates. Stillother operations and steps are possible.

Using machine-learning to detect atrial fibrillation using patterns ofECG features that are known to be indicative of atrial fibrillationallows more flexibility in detecting instances of atrial fibrillationthan when the detection is based on a single set of predefinedparameters. FIG. 14 is a flow diagram showing a method 170machine-learning-based atrial fibrillation detection with the aid of adigital computer in accordance with one embodiment. The method can beimplemented on the server 122 of FIG. 3, though other implementationsare also possible. Prior to classification of ECG data as beingindicative of atrial fibrillation, an adaptive atrial fibrillationdetector is trained, as further described with reference to FIG. 15below (step 171). In one example, the adaptive atrial fibrillationdetector can be implemented by a convolutional neural network thatrepresents a processing device, such as an algorithm executed by acomputer processor or actual hardware. Other types of network systemsare possible.

ECG data collected from a patient via a ECG monitor, such as the monitordescribed above with respect to FIGS. 1-10, though other monitors arepossible, is analyzed to determine presence of portions of the dataindicative of atrial fibrillation, as further described below withreference to FIG. 16 (172). An action is taken following the analysis(step 173), ending the method 170. Such action can include sending areport of the analysis, such as via mail, though other ways of providingthe report are possible, to the patient, the physician who prescribedthe monitoring, or another party authorized to receive the report. Ifthe analysis reveals portions of ECG data being associated with atrialfibrillation, an alert can also be sent electronically, such as via ane-mail or an SMS message, to the patient, the physician's patient, oranother party authorized to receive the alert. Further, a detectedpattern can be added to the ECG training data and subsequently used totrain the adaptive atrial fibrillation detector. Other actions are alsopossible.

Accurate detection of presence of atrial fibrillation during ECGmonitoring of the ECG data segments is dependent on training accuracy.FIG. 15 is a flow diagram showing, by way of example, a routine 180 fortraining an adaptive atrial fibrillation detector for use in the method170 of FIG. 14. ECG training data, described above with reference toFIG. 3, is obtained (step 181).

The training data is divided into segments, with each segmentcorresponding to a temporal window during which the portion of the ECGsignal in that segment was recorded (step 182). In one embodiment, thetemporal window can be between 2 and 12 seconds; for example in oneembodiment, the temporal window can be 8.5 seconds. Patterns of ECGfeatures within the segments are annotated as being indicative of atrialfibrillation or not being indicative of atrial fibrillation (step 183).In one embodiment, a total of 32 unique patterns of ECG features isannotated, though other numbers of combinations are also possible.

The annotated patterns are then provided to the adaptive atrialfibrillation detector (step 184). In one embodiment, the patterns areeach provided and run through the adaptive atrial fibrillation detectoronce. In a further embodiment, the patterns are run through the adaptiveatrial fibrillation detector multiple times.

After the training data has been run through the adaptive atrialfibrillation detector, testing can be performed to determineclassification accuracy of the adaptive atrial fibrillation detector(step 185). During testing, a set of testing data, such as ECGmonitoring results collected by ambulatory ECG monitors, such asdescribed above with reference to FIGS. 1-10 above, is run through thetrained adaptive atrial fibrillation detector, which classifies thetesting data. Additionally, the testing data is annotated manually orvia a different program with classifications of being indicative of thepatient experiencing atrial fibrillation at the time the data wascollected or not. A comparison is made between the annotation of thedata and the results of the adaptive atrial fibrillation detector. Anumber of samples correctly classified is determined and an averageaccuracy of the testing data is determined. In one embodiment, theaverage accuracy can be determined and reported after every n number ofbatches of ECG data. For example, n can represent 100 batches; however,other numbers of batches are possible. The batches can be determinedbased on an amount of ECG data, a number of ECG ambulatory monitorsproviding the data, as well as by other metrics. An accuracy thresholdcan be applied to the average accuracy values and if an average accuracyvalue or a predetermined number of average accuracy values are below thethreshold, further training can be performed (block 307) to increase theaccuracy of the adaptive atrial fibrillation detector.

Once the adaptive atrial fibrillation detector is accurately trained,further ECG data is collected and provided to the detector forclassification. FIG. 16 is a flow diagram showing, by way of example, aroutine 190 for classification of ECG data for use in the method 170 ofFIG. 14 in accordance with one embodiment. The collected ECG data isdivided into segments corresponding to temporal windows during which theportions of the ECG data included in the segments were collected, asdescribed above with reference to step 182 (step 191). Optionally, noisefiltering of the segments is performed prior to further processing ofthe segments, as further described in detail in U.S. Pat. No.10,251,576, issued Apr. 9, 2019, the disclosure of which is incorporatedby reference, and only non-noise ECG data segments are subjected tosubsequent processing (step 192). The ECG data segments are thenreceived by the trained adaptive atrial fibrillation detector (step193). As described above with reference to FIG. 3, the detector can beimplemented by a convolutional neural network utilizing, for example, aone dimensional formulation for use with ECG data. Additionally, theadaptive atrial fibrillation detector can include hidden layers forperforming the classification. In the embodiment described below, twoconvolutional or pooling hidden layers, and two fully-connected hiddenlayers are utilized. However, other number of layers are possible.

During the first convolution layer, ECG trace features are identified(block 193) using, for example, sliding filters, though otheridentification techniques are possible. Examples of ECG trace featurescan include R waves without clearly discernible P waves, as well asother types of features that are indicative of atrial fibrillation. Forexample, other patterns indicative of AF can further include highlydisorganized P-waves that do not settle into a repeating pattern. In oneembodiment, filters for at least 32 features are run against the ECGdata. During the second convolution layer, repeating patterns of thefeatures are identified (step 194), including, for example, irregular Rintervals between successive R-waves, though other patterns arepossible.

Next, the data obtained from the second convolution layer is provided toa first fully connected cross-connection layer, which builds (step 195)a matrix with the repeating features representing the columns and matrixmultipliers representing rows. An intersection value for eachcombination of the repeating features and matrix multipliers are listedin the matrix as cross connection weights. Specifically, theintersection value can be determined by multiplying each repeatingfeature value with a matrix multiplier and scaling the product by apredetermined factor. However, other methods for determining theintersection values are possible.

The second fully connected cross-connection layer utilizes thecross-connection weights from the first fully connected cross-connectionlayer and multiplies the cross-connection weights by further weights tocalculate (step 196) final cross-connection values for each ECG datasegment. The final cross-connection values include an atrialfibrillation classification value, which is indicative of a probabilitythat the patient experienced atrial fibrillation during the temporalinterval during which the ECG data segment was recorded, and anon-atrial fibrillation data classification value, which is indicativeof the probability that the patient did not experience atrialfibrillation during the temporal period during which the ECG datasegment was recorded.

Based on the final cross-connection values, a determination is made asto whether the atrial fibrillation classification value for each datasegment exceeds the non-atrial fibrillation classification value (step197). The ECG data segments for which the atrial fibrillationclassification value does exceed the non-atrial fibrillationclassification value are classified as associated with atrialfibrillation of the patient (step 198), signifying that the patientexperienced atrial fibrillation during at least a portion of thetemporal windows during which these ECG data segments were recorded. Forthose ECG data segments for which the atrial fibrillation classificationvalue does not exceed the non-atrial fibrillation classification value(197), a non-atrial fibrillation classification is assigned (step 199),signifying that the patient did not experience atrial fibrillationduring the temporal windows during which these ECG data segments wererecorded.

While the invention has been particularly shown and described asreferenced to the embodiments thereof, those skilled in the art willunderstand that the foregoing and other changes in form and detail maybe made therein without departing from the spirit and scope.

What is claimed is:
 1. A system for neural-network-based atrialfibrillation detection with the aid of a digital computer, comprising: adatabase operable to maintain a plurality of electrocardiography (ECG)features and annotated patterns of the features, at least some of thepatterns associated with atrial fibrillation; at least one serverinterconnected to the database and implementing a convolutional neuralnetwork, the convolutional neural network comprising two convolutionalhidden layers and two fully-connected hidden layers, the at least oneserver configured to: train a classifier based on the annotated patternsin the database, the classifier implemented by the convolutional neuralnetwork; receive a representation of an ECG signal recorded by one ormore cardiac monitors; detect via a first one of the convolutionalhidden layers a plurality of the ECG features in at least some of theportions of the representation; use the trained classifier via a secondone of the convolutional hidden layers to identify patterns of the ECGfeatures within one or more of the portions of the ECG signal; generatevia a first one of the fully-connected hidden layers at least one matrixwith weights for the patterns; for each of the portions, calculate via asecond one of the fully-connected hidden layers using the at least onematrix a value indicative of whether that portion of the representationis associated the patient experiencing atrial fibrillation; determinethat one or more of the portions of the ECG signal are associated withthe patient experiencing atrial fibrillation using the scores for thoseportions.
 2. A system according to claim 1, the at least one serverfurther configured to: obtain ECG training data; divide the ECG trainingdata into a plurality of segments, each of the segments associated witha temporal window; receive annotations for one or more patterns of ECGfeatures in the segments; and set the annotated patterns of the featuresin the database based on the received annotations.
 3. A system accordingto claim 2, wherein the temporal windows are between 2 and 60 seconds.4. A system according to claim 2, the at least one server furtherconfigured to extract the ECG features from the ECG training data.
 5. Asystem according to claim 4, wherein same cardiac waves of differentshapes are stored as different one of the ECG features in the database.6. A system according to claim 1, the at least one server furtherconfigured to detect noise in portions of the ECG signals, wherein theECG features are not detected in those portions of the ECG signals thatcomprise the noise.
 7. A system according to claim 1, the at least oneserver further configured to: take an action upon making thedetermination that one or more of the portions of the ECG signal areassociated with the patient experiencing atrial fibrillation.
 8. Asystem according to claim 7, the at least one server further configuredto: store the determination in electronic medical records associatedwith the patient.
 9. A system according to claim 7, wherein the actioncomprises sending an alert regarding one or more of the determinations.10. A system according to claim 9, wherein the alert comprises one ormore of an SMS message and an e-mail message.
 11. A method forneural-network-based atrial fibrillation detection with the aid of adigital computer, comprising: maintaining in a database a plurality ofelectrocardiography (ECG) features and annotated patterns of thefeatures, at least some of the patterns associated with atrialfibrillation; training by an at least on server interconnected to thedatabase a classifier based on the annotated patterns in the database,the at least one server implementing a convolutional neural network, theconvolutional neural network comprising two convolutional hidden layersand two fully-connected hidden layers, wherein the classifierimplemented by the convolutional neural network; receiving by the atleast one server a representation of an ECG signal recorded by one ormore cardiac monitors; detecting by the at least one server via a firstone of the convolutional hidden layers a plurality of the ECG featuresin at least some of the portions of the representation; using by the atleast one server the trained classifier via a second one of theconvolutional hidden layers to identify patterns of the ECG featureswithin one or more of the portions of the ECG signal; generating by theat least one server via a first one of the fully-connected hidden layersat least one matrix with weights for the patterns; for each of theportions, calculating by the at least one server via a second one of thefully-connected hidden layers using the at least one matrix a valueindicative of whether that portion of the representation is associatedthe patient experiencing atrial fibrillation; determining by the atleast one server that one or more of the portions of the ECG signal areassociated with the patient experiencing atrial fibrillation using thescores for those portions.
 12. A method according to claim 11, furthercomprising: obtaining by the at least one server ECG training data;dividing by the at least one server the ECG training data into aplurality of segments, each of the segments associated with a temporalwindow; receiving by the at least one server annotations for one or morepatterns of ECG features in the segments; setting by the at least oneserver the annotated patterns of the features in the database based onthe received annotations.
 13. A system according to claim 12, whereinthe temporal windows are between 2 and 60 seconds.
 14. A methodaccording to claim 12, the at least one server further configured toextract the ECG features from the ECG training data.
 15. A methodaccording to claim 14, wherein same cardiac waves of different shapesare stored as different one of the ECG features in the database.
 16. Amethod according to claim 11, the at least one server further configuredto detect noise in portions of the ECG signals, wherein the ECG featuresare not detected in those portions of the ECG signals that comprise thenoise.
 17. A method according to claim 11, further comprising: taking anaction by the at least one server upon making the determination that oneor more of the portions of the ECG signal are associated with thepatient experiencing atrial fibrillation.
 18. A method according toclaim 17, further comprising: storing by the at least one server thedetermination in electronic medical records associated with the patient.19. A method according to claim 17, wherein the action comprises sendingan alert regarding one or more of the determinations.
 20. A methodaccording to claim 19, wherein the alert comprises one or more of an SMSmessage and an e-mail message.